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U <br /> UNIFIED PROGRAM CONSOLIDATED FORM 1 Jf'/Oq <br /> UNDERGROUND STORAGE TANK <br /> OPERATING PERMIT APPLICATION-FACILITY INFORMATION <br /> (One form per facility) <br /> TYPE OF ACTION C11.NEW PERMIT El 5.CHANGE OF INFORMATION [17.PERMANENT FACILITY CLOSURE 4m. <br /> /Check..,item only) RENEWAL PERMIT ❑ 6.TEMPORARY FACILITY)CLOSURE ❑ 9.TRANSFER PERMIT <br /> I. FACILITY INFORMATION <br /> TOTAL NUA- ER OF USTs AT I1-I1N FACILITY ID# <br /> (Agency Use Only) `I J• <br /> BUSINNEENAME(Sa eat Facil' Nameor DBA-Doing Business As) 3_ <br /> BUSINESS SITE ADDRESS 103. CITY / IN, <br /> FACH,ITY TYPE PO-.'MOTOR VEHICLE FUELING ❑ 2.FUEL DISTRIBUTION "o3Is the facility located on IndianBaservation or 405. <br /> ❑ 3.FARM ❑ 4.PROCESSOR ❑ 6.OTHER Trust lands? ❑ I.Yes FJ7.No <br /> IL PROPERTY OWNER INFORMATION <br /> PROPERTY,OWNER NAME 407. PHONE 401. <br /> L, �} 2� 3z7 - G3 � S <br /> MAILIN DDRE 4m' <br /> �o . (Sz3 <br /> CITY410. STATE 411. ZIP CODE 412. <br /> ci z�r <br /> III. TANK OPERATOR INFORMATION <br /> TANK OPERATOR NAME 428-1, PHONE 4282. <br /> MAILING ADDRESS 4a.3' <br /> CITY 4284- STATE 428-5, ZIPCODE 429s. <br /> IV. TANK OWNER INFORMATION <br /> TANK OWNER NAME �-• A v4. PHONE 415. <br /> MAILING ADDRESS 416. <br /> CITY 417. 1 STATE ata. 1 ZIP CODE Oro. <br /> OWNER TYPE: ❑ 4.LOCAL AGENCY/DISTRICT E❑ 5.COUNTY AGENCY [16.STATE AGENCY 420 <br /> ❑ 7.FEDERAL AGENCY 1118.NON-GOVERNMENT <br /> V. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER <br /> TY(TK)HQ 44_ Q / Call the State Board of Equalization,Fuel Tax Division,if there are questions. 4'1 <br /> VI. PERMIT HOLDER INFORMATION <br /> Issue permit and send legal notifications and mailings to: R<FACILITYOWNER ❑ 4.TANK OPERATOR <br /> 423, <br /> ❑ 3.TANK OWNER ❑ 5.FACILITY OPERATOR <br /> SUPERVISOR OF DIVISION,SECTION,OR OFFICE(Required for Public Agencies Only) 4% <br /> VII.APPLICANT SIGNATURE <br /> rFATjFJC±,P certify that e i formation provided herein is true accurate and in f I compliance with legal re uirement3. <br /> P 1 T G RE DATE !.r 4�4 PHONE <br /> 4u. <br /> APPLICA NAME5.(print) 426. APPLIC NT TI,E 4n <br /> UPCF UST-A Rev.(12/200')-1/2 w w.unidocs.org N! <br />